What would you do?

Ken, the copay for a physician is for a new encounter. For an example, my semiannual urologist visits are as a continuation of treatment so the copay doesn’t apply. Recently I had a finger arthritis problem that required surgery. I saw the surgeon four times and only paid the copay one time, the initial visit.

As to the balance billing issue, that only applies to providers that are not fully enrolled in Medicare, but accept direct payments. Less than 2% of providers are in this status. Plus the balance billing is capped at 15% of the Medicare amount and has to be disclosed before treatment. So on a $100 office call, the most the balance billing can be is $15. Not a problem or reason to not choose N. And I have never experienced the balance billing. According to CMS, the providers that can charge for balance billing are primarily mental health providers, ie. psychiatrists. Very simple to ask your providers their status. I would be very surprised to learn that any of your docs can subject you to this 15% surcharge.

Plan G is the default plan that you are put into within employer/retiree plans and upon guaranteed issue at first eligibility, usually age 65. At this time they do not ask any health information, but you pay a higher premium. Kind of like guaranteed issue life insurance. To get to any other plan, you must request it and provide health and treatment information. At that time the insurance company will determine your risk and insurability status a provide a premium rate, or deny the coverage. When I did this our premium dropped about 40%. Well worth the effort. My PCa and my wife’s twice breast cancers were not an issue as it had been more than two years since any treatments. The worst thing is to sit on the status as you may be paying a higher premium forever. Even if you want to stay on Plan G at least try to get a better premium. However in an employer sponsored retiree benefit plan, I doubt they will let you as they need the higher premium for the less desirable risks they must cover.

First, the Plan N office call copay does not apply until you have met your Plan B deductible of $226 in 2023. So many office calls in the early part of the year will not attract the copay. If you are fortunate enough not to exhaust your deductible in a year you will not have any office copays. Thus, the same out of pocket provider expense as Plan G, but typically far less premium.

Second, the copay is up to $20, but can be less. It is not more than 20% of the Medicare approved payment for the visit, or $20 maximum. So if Medicare approves $80, then the copay would be $16 not $20. If Medicare approves $150, the copay is $20.

Third, it does not distinguish between GP and Specialist. Medicare Advantage Plans often have different copays for a GP and a Specialist. For example, it is common to have copays of $20 for GP and $50 for specialist. Plan N limit is $20 regardless of provider status.

Fourth, the copay generally does not apply to visits where a service is provided, like an X-ray, vaccination, ECG, etc. For example, I have two physical exams each year, one that has an ECG, both draw blood, the one in the fall includes flu vaccine. I have not been charged a copay for these visits. One is the annual Medicare assessment and never has a copay anyway. When I see my urologist twice a year and have my PSA blood draw, I have not been charged a copay. I see my ophthalmologist at least six times a year. Often I have a treatment shot. When I do have a treatment shot, I am not charged a copay. This year I have had three visits and a shot each time and have not been charged a copay. There are 16 CMS billing codes the provider can use that trigger the copay. So the key is in the billing code. A couple of times I have been charged the copay and questioned the provider and they amended the claim with a billing code that eliminated the copay. They get their money either way.

It is now mid July and this year my wife has had one $16 copay and I have had two $20 copays; total copays $56. Our Plan N combined premium is more than $100 per month less than our Plan G premium was. So far in 2023 I have saved more than $700 in premium. No way office visit copays will ever erode the premium savings compared to Plan G. In 2023 our Plan N premium did not increase, but I have read reports that average Plan G premiums increased about 6%. I continue to be elated with my decision to shift to Plan N and continue to suggest others do so. I would be suspect of any advisor that discounts Plan N in favor of Plan G particularly if they are not well versed in the long term historical comparisons of premium increases of Plans F, G and N. Since Plan F is no longer available and Plan G is now the default guaranteed issue plan, it will certainly experience the same adverse selection that plagued Plan F and led to annual premium increases that averaged more than 3x that of Plan N for more than a decade. It is only prudent to expect the same increase differential going forward for Plan G. Anyone that is afraid of the limited office visit copays of Plan N doesn’t understand Medicare Supplements, and certainly has not assessed the expected exposure a specific person is expected to have. The absence of such an assessment, to me, demonstrates professional carelessness. Thus, more information is needed for many people and I will do my best to help.

Jack,

All very interesting. I suppose if I had asked my advocate how the copay situation in plan N worked, he might well have given the explanation. I did not ask. I saw, on the chart, literally "$20 copay per physician visit" with an asterisk, and the questionnaire asked "how many doctor visits do you have per month?", and if it was <1, then they steer towards N, but it if is 3 or more, they steer towards G.

After reading the asterisks, it still doesn't clarify the follow up vs original visit point.

In short, this is a gov't program. It hast to be confusing and hard to decipher. That's just how it is.

What if halbert is a government scientist?

I get it. What we see, in PA, is a monthly premium difference between G and N of about $30/month. There will an opportunity to re-evaluate in November for 2024.

Now, if we could just get the D plans to cover cialis.....

Mumbo, no I work in private industry. For another 10 months. But I'm not counting.

My head is exploding.
Will that be covered in any of these plans?

😀

JNF said...
Ken, the copay for a physician is for a new encounter. For an example, my semiannual urologist visits are as a continuation of treatment so the copay doesn’t apply. Recently I had a finger arthritis problem that required surgery. I saw the surgeon four times and only paid the copay one time, the initial visit.

As to the balance billing issue, that only applies to providers that are not fully enrolled in Medicare, but accept direct payments. Less than 2% of providers are in this status. Plus the balance billing is capped at 15% of the Medicare amount and has to be disclosed before treatment. So on a $100 office call, the most the balance billing can be is $15. Not a problem or reason to not choose N. And I have never experienced the balance billing. According to CMS, the providers that can charge for balance billing are primarily mental health providers, ie. psychiatrists. Very simple to ask your providers their status. I would be very surprised to learn that any of your docs can subject you to this 15% surcharge.

Plan G is the default plan that you are put into within employer/retiree plans and upon guaranteed issue at first eligibility, usually age 65. At this time they do not ask any health information, but you pay a higher premium. Kind of like guaranteed issue life insurance. To get to any other plan, you must request it and provide health and treatment information. At that time the insurance company will determine your risk and insurability status a provide a premium rate, or deny the coverage. When I did this our premium dropped about 40%. Well worth the effort. My PCa and my wife’s twice breast cancers were not an issue as it had been more than two years since any treatments. The worst thing is to sit on the status as you may be paying a higher premium forever. Even if you want to stay on Plan G at least try to get a better premium. However in an employer sponsored retiree benefit plan, I doubt they will let you as they need the higher premium for the less desirable risks they must cover.

Thanks Jack, this is very helpful.
Regarding my situation, I am hopeful I don't have to deal with it, we have 3 cases against the city right now, so far we have won one case before these three, and on the major case in court right now, we have so far won a TRO that stops everything until the case is decided , so we will see.

With that said, in NY State, there is no underwriting, even if we move from plan to plan. I think there are 4 states that have guaranteed issue with no uncharges for/or pre-existing conditions, Now, if I ultimately declare Florida residency, which is possible, that would change. However my understanding is that whatever plan I am in, at least with United Healthcare, which is what most NY medicare recipients purchase, I can take it with me and choose either the Florida or NY premium, whichever is lower.

Thanks for the info on balance billing and copays. Very helpful

Nels, not that I am anticipating any new surgeries or anything else big--but I am really looking forward to no longer having a $3000 annual deductible and a $6000 annual out of pocket.....Paying $200 on a 50K plus bill sounds really good!

Mumbo, the logic is that a certain group of politicians want people to "take responsibility for their medical care" and "have some skin in the game" when it comes to paying for care. Forcing people to actually pay out of pocket is their answer to dealing with the high cost of medical care. As if, somehow, shifting the burden of payment to the individual will somehow "let the market decide" what medical care costs.

As it was explained to me, the purpose of the deductible was to deter over-utilization, that is, to keep people from going to the doctor for a runny nose.